The present invention is directed to methods for administering preventative healthcare to a patient population eligible to receive healthcare benefits in order to improve the quality component of treatment outcomes.
The healthcare industry is largely driven by compensation based on utilization. Hospitals, specialists and ancillary providers in the past were typically compensated based on utilization, which as a consequence led to increased utilization and wastage of healthcare resources. To prevent over-utilization and over-billing, payers (i.e., insurance companies and the like) began to capitate some of the services provided under managed care in order to limit the amount of dollars being spent. While this approach was generally effective in limiting total spending, such approach did not improve the quality component of treatment outcomes.
The Affordable Care Act, implemented as part of sweeping healthcare reform, introduced much needed changes in the healthcare industry. One major item was the introduction of Accountable Care Organizations (ACO's) that would attempt to address the problems being faced by the healthcare industry today which, among other things, included emphasizing the component of healthcare quality whereby reimbursement would be based not on utilization patterns but on treatment outcomes. For example, providers would receive additional compensation for performing post-discharge planning, working with other providers for preventing unnecessary emergency room admissions, made meaningful use of electronic healthcare records (EHR), implementing preventative healthcare measures, and the like.
Since the ACO concept is completely new for managed care organizations (e.g., HMO's) and/or traditional ways for providing care, a substantial need in the art has been created for new types of methods that, in the delivery of healthcare, enables healthcare providers and care coordinators such as nurses and case managers to render services in terms of “accountable care.” Such practices would include additional documentation, coordination of care, increased focus on complex case management and disease management, automated updates of eligible beneficiaries and disease rosters, call logs, and the like. Such practices would further preferably integrate and interface with multiple data sources such as claims, beneficiaries' eligibility, pharmacy, lab data, accounting data and the like so as to create an aggregation of data compiled into a single database that would enable healthcare to be administered to achieve optimal patient outcomes and objective healthcare quality. In this regard, there is a substantial need in the art for methods that can enable healthcare to be administered with emphasis on quality, particularly with respect to preventative care whereby healthcare can be administered that can ensure that quality measures and preventative care, such as outstanding vaccinations and the like, can be administered to a specified patient population that is substantially more cost effective and efficient than current methods.